3 Post-Activity Survey

OMB No.: 0906-0104
Expiration Date: 11/30/2027

Participant Program Evaluation Form
{Insert Description/Date(s) of Activity}

Please take the necessary time to respond to each item on this evaluation form. Your candid and complete responses
are important so that we can better meet your learning needs.
A. Check the box that rates your ability to meet objectives BEFORE and AFTER the activity:
Please rate your
BEFORE you participated:
AFTER you participated:
ability to:

1. {Insert Objective}
2. {Insert Objective}
3. {Insert Objective}
4. {Insert Objective}
5. {Insert Objective}

Poor

(less than
59% able)

Average
(60-69%
able)

Good

(70-79%
able)

Great

(80-89%
able)

Excellent
(90-100%
able)

Poor

(less than
59% able)

Average

Good

(60-69%
able)

Great

(70-79%
able)

(80-89%
able)

Excellent
(90-100%
able)

Remove unnecessary rows.
B. Circle the number that indicates your level of agreement with the following statements:
Strongly
Disagree

1. The stated objectives were achieved.
2. The mode of delivery for this activity was conducive to {insert “learning” or
“productivity”}.
3. The technology used to deliver the activity was conducive to
learning/productivity.
4. The materials were effective.
5. The activity was relevant to my work.
6. Overall I am satisfied with the activity.
7. The activity was objective, science-based, and free of commercial bias.

Remove if unnecessary for CEU

C (Optional). Check the box that rates the faculty (presenters/facilitators):

Strongly
Agree

1
1

2
2

3
3

4
4

5
5

1

2

3

4

5

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

Faculty 1: {insert name}
1. Expertise in topic area(s).
2. Effectiveness of teaching/facilitation strategies.

Poor

Average

Good

Great

Excellent

Faculty 2: {insert name}
1. Expertise in topic area(s).
2. Effectiveness of teaching/facilitation strategies.

Poor

Average

Good

Great

Excellent

OMB No.: 0906-0104
Expiration Date: 11/30/2027

D. Please write your responses to the following questions:
1. As a result of participating in this activity, what do you intend to do or do differently in your work? Examples may
include (check all that apply}.
N/A
Yes
No
Maybe
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
{Insert potential action item}
Other (please describe):

Remove unnecessary rows.
2. How could this activity be changed, modified, or improved? Please include comments about what additional
information or support you would find helpful.

Public Burden Statement: The purpose of this collection is to assist with preparing for, and evaluating the reach and
effectiveness of, select meetings and workshops conducted by HRSA’s Office of Intergovernmental and External Affairs.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0104
and it is valid until 11/30/2027. This information collection is voluntary. Data will be private to the extent permitted by
the law. Public reporting burden for this collection of information is estimated to average 3.33 minutes per response,
including the time for reviewing instructions, searching existing data sources, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600
Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/
about/508-resources for the HRSA digital accessibility statement.